Table Of ContentAtlas of Pelvic Floor Ultrasound
Hans Peter Dietz, Lennox P.J. Hoyte, and Anneke B. Steensma
Atlas of Pelvic
Floor Ultrasound
Hans Peter Dietz, MD, PhD, FRANZCOG, Lennox P.J. Hoyte, MD, MSEECS,
DDU, CU FACOG
Associate Professor in Obstetrics and Assistant Professor of
Gynaecology Obstetrics, Gynecology, and
University of Sydney Reproductive Biology
Nepean Clinical School Harvard Medical School
Penrith, NSW, Australia and
http://www.med.usyd.edu.au/~pdietz/ Staff Urogynecologist
Site/Welcome.html Brigham and Women’s Hospital
Boston, MA, USA
Anneke B. Steensma, MD
Gynaecologist
Department of Gynae-Oncology
Erasmus Medical Center
Rotterdam, The Netherlands
British Library Cataloguing in Publication Data
Dietz, Hans Peter
Atlas of pelvic fl oor ultrasound
1. Pelvic fl oor — Ultrasonic imaging — Atlases
I. Title II. Hoyte, Lennox P. J. III. Steensma, Anneke B.
617.5′507543′0222
ISBN-13: 9781846285202
ISBN-10: 1846285208
Library of Congress Control Number: 2006930109
Printed on acid-free paper
ISBN: 978-1-84628-520-2 eISBN: 978-1-84628-584-4
© Springer-Verlag London Limited 2008
The software disk accompanying this book and all material contained on it is supplied
without any warranty of any kind. The publisher accepts no liability for personal injury
incurred through use or misuse of the disk.
Apart from any fair dealing for the purposes of research or private study, or criticism or
review, as permitted under the Copyright, Designs and Patents Act 1988, this publication
may only be reproduced, stored or transmitted, in any form or by any means, with the prior
permission in writing of the publishers, or in the case of reprographic reproduction in accor-
dance with the terms of licences issued by the Copyright Licensing Agency. Enquiries con-
cerning reproduction outside those terms should be sent to the publishers.
The use of registered names, trademarks, etc. in this publication does not imply, even in the
absence of a specifi c statement, that such names are exempt from the relevant laws and regu-
lations and therefore free for general use.
Product liability: The publisher can give no guarantee for information about drug dosage
and application thereof contained in this book. In every individual case the respective user
must check its accuracy by consulting other pharmaceutical literature.
9 8 7 6 5 4 3 2 1
Springer Science+Business Media
springer.com
Foreword
Pelvic fl oor ultrasound is often described as a niche investigation within
obstetrics and gynecology and even within gynecological ultrasound. After
reading this book, I am convinced that it should be a mainstream investiga-
tion taught to all fellows and subspecialty trainees. Nothing should be of
more importance to obstetricians and gynecologists than the protection of
the pelvic fl oor of their patients and effective treatment when disorders
arise. These disorders cause more prolonged and disruptive misery to
patients than many of the conditions that clog up the waiting list in obstet-
rical and gynecological departments.
This book is more than an “atlas”; it is an education in the anatomy and
dynamics of the lower urinary tract and pelvic fl oor and the investigation
of disorders that occur, such as incontinence and prolapse. Ultrasound,
despite its preeminence as an investigative tool in obstetrics and gyneco-
logy, has been slow to achieve such status in urogynecology, principally
because the transvaginal ultrasound probe which is the standard tool in
gynecologic scanning distorts the pelvic fl oor anatomy. This makes inter-
pretation of prolapse impossible. It was the realization that perineal or
translabial ultrasound provided equally good and artefact-free information
on bladder dynamics and the integrity of the pelvic fl oor that a change in
attitude occurred. However, many urogynecologists are still reluctant to
supplement their multichannel recorders for urodynamic testing and X-ray
video-cine-urethrography which were part of their training as junior
doctors. The convincing images in this book must surely hasten the day
when ultrasound becomes the standard technique in the investigation of
pelvic fl oor problems.
Although this book contains an excellent chapter and images of MRI of
the pelvic fl oor, it is the ultrasound techniques and images that predomi-
nate. This is not surprising because ultrasound has several advantages over
competing imaging techniques; the equipment is readily available and most
trainee gynecologists have experience in its use. Ultrasound is inexpensive,
causes minimal discomfort to the patient, and can be used to study the
dynamics of the pelvic fl oor in real time, for example bladder neck mobility.
Furthermore, ultrasound is now entering an exciting new era of 3D imaging,
which provides access to the axial plane, to study the levator hiatus and
v
vi Foreword
also, can create stunning tomographic 3D-rendered images of the complete
pelvic fl oor.
Hans Peter Dietz has been working in this fi eld for twenty years. He is
one of the pioneers of transperineal/translabial ultrasound and is now the
acknowledged expert in 3D/4D imaging of the pelvic fl oor. The images and
text in this book are therefore based on his considerable experience in
urogynecological investigation. Indeed, an invaluable chapter is a series of
cases in which he presents the case history and report of fi fteen patients,
all with different clinical presentations of pelvic fl oor complications. It is
in this section that the strength of ultrasound in investigation of inconti-
nence and prolapse is convincingly demonstrated. Perhaps just one example
(case number 10) will convince the reader that this is the technique of the
present and future for such abnormalities. The case is of a woman referred
nine months after a rotational forceps delivery, complaining of urgency,
urge incontinence, sensation of prolapse and incomplete bowel emptying.
Dr. Dietz’s report is given below.
Findings:
2D: There was a postvoid residual of approximately 70 mL. The urethra
appeared normal. We saw 44 mm of bladder neck descent on Valsalva, with
the retrovesical angle opening up to 180∞, 80∞ of urethral rotation, but no
funneling. A cystocele descended to about 15 mm, below the symphysis; the
uterus to 13 mm below. Detrusor wall thickness was normal at 3.5 mm. There
was no defect of the rectovaginal septum.
3D: There was a major bilateral avulsion injury of the pubovisceral muscle,
worse on the right, with complete loss of paragainal tenting. The hiatus
measured more than 6 cm in the coronal plane, and the defects measured
almost 3 cm in width. Although dimensions in the sagittal plane remained
reasonable, the severe damage to levator insertions bilaterally caused
marked ballooning of the hiatus to 43 cm squared.
Interpretation: Moderate cystocele with open RVA but no funnelling. Moder-
ate uterine prolapse. Normal posterior compartment. Major bilateral avul-
sion defect of the pubovisceral muscle and severe ballooning. Marked risk of
prolapse recurrence. . . . Her anterior compartment prolapse is probably
incurable unless one uses mesh interposition. . . .
The case highlights several of the important advantages of ultrasound in
the assessment of the pelvic fl oor. Ultrasound alone was able to identify the
damage to the levator hiatus thus providing information on the risk of
prolapse recurrence and the most appropriate treatment. Axial plane
imaging has the potential to revolutionise our approach to pelvic fl oor
problems. Dr. Dietz has established that if the levator hiatus enlarges to
more than 35 cm2 on Valsalva, (i.e., ballooning) then the degree of disten-
tion is associated with prolapse. Not only this, but ballooning is probably
associated with recurrence after repair hence his advice on mesh interposi-
tion. It has been estimated that up to 50% of women have some degree of
pelvic fl oor damage after vaginal birth. Dr. Dietz believes antenatal pelvic
Foreword vii
fl oor ultrasound will help to identify women at high risk of operative deliv-
eries and signifi cant pelvic fl oor damage. Ultrasound also provides audit
of new surgical procedures to assess their effectiveness in providing for
example durable and effective elevation of the bladder neck, and there is
an excellent chapter on imaging of implant materials. Ultrasound is chal-
lenging conventional wisdom in many areas such as the need for hysterec-
tomy as part of pelvic fl oor repair and the value of clinical examination in
the assessment of prolapse.
Dr. Dietz and his colleagues must be congratulated for producing an
instructive and challenging book that will be of value not just to trainees
in urogynecology but to obstetricians, gynecologists, midwives, colorectal
surgeons indeed all professionals concerned with the prevention and man-
agement of pelvic fl oor disorders. The stunning 3D images will I hope con-
vince even the most conservative of professionals that ultrasound has a
unique and important part to play in the investigation of pelvic fl oor dis-
orders. In a way this book is just a start; the next step is to develop training
programmes and obtain the latest equipment so that women can benefi t
from these recent advances. This book, however, is an important and neces-
sary fi rst step.
Stuart Campbell, DSc, FRCPEd, FRCOG
Preface
The increasing availability of ultrasound and magnetic resonance (MR)
imaging equipment has, over the last decade in particular, triggered a
renewed interest in diagnostic imaging in female urology and urogy-
necology. Although MR provides excellent resolution and contrast and is
a wonderful tool for describing anatomy (as Lennox Hoyte will show),
ultrasound has found more widespread use. This is attributable to cost
and access issues, but also because ultrasound offers a degree of dynamic
imaging that is not currently achievable by MR. Ultrasound, at least in
the form of two-dimensional (2D) B mode real-time sonography, is
almost universally available and provides for real-time observation of
maneuvers such as Valsalva and pelvic fl oor muscle contraction. This is
of great importance when assessing pelvic fl oor anatomy and function
because maneuvers enhance the visibility of structures and help uncover
defects.
A number of different sonographic approaches have been used for lower
urinary tract and pelvic fl oor imaging. From the 1980s onward, transab-
dominal,1,2 perineal,3,4 transrectal,5 and transvaginal ultrasound6 have been
investigated for use in women with urinary incontinence and prolapse.
Because of its noninvasive nature, ready availability, and the absence of
distortion, perineal or translabial ultrasound is currently used most widely.
However, most of the text in this volume (and many of the images) will also
apply and be useful to colleagues more familiar with introital ultrasound,
a method that generally uses transducers designed for intravaginal use, by
placing them in the vestibule of the vagina.
One of the advantages of translabial or perineal ultrasound is that it
allows the use of standard curved array transducers designed for abdomi-
nal and obstetric imaging. Another is the fact that the characteristics of
such transducers usually permit imaging of the entire levator hiatus. This
includes the anorectum, allowing us to fi nally see beyond the confi nes of
our respective specialties. Pelvic fl oor morbidity encompasses urologic,
gynecologic, and colorectal abnormalities, and modern imaging may well
come to be a factor that leads to a closer integration of those three special-
ties. Colorectal pelvic fl oor imaging is still in its infancy, with sphincter
assessment the only area that has developed beyond the experimental stage
ix
x Preface
at present, but hopefully Anneke Steensma’s chapter will help demonstrate
the potential of sonography in this fi eld.
The development of 3D ultrasound has opened up entirely new diagnostic
possibilities in pelvic fl oor imaging, not the least because it has given us
access to the axial plane, i.e., the plane of the levator hiatus. First attempts
at producing 3D-capable systems go back to the 1970s when the processing
of a single volume of data would have required 24 hours of computer time
on a system large enough to fi ll a small room. Such data processing is now
possible on a laptop computer, and in real time. The advent of volume
ultrasound has also allowed the use of rendering techniques for contrast
enhancement and speckle reduction. As a result, resolutions in all potential
planes have improved markedly over the last few years and we have made
great progress in evaluating pelvic fl oor function and trauma. Transvaginal
and translabial techniques of 3D ultrasound allow higher frequencies, and
although they suffer from a restricted fi eld of view, resolution can poten-
tially be much higher. It is likely that there will be signifi cant development
of this fi eld in the next few years.
We have no evidence that modern imaging techniques improve patient
outcomes in pelvic fl oor medicine, and it would be a major challenge to try
to conduct a trial to prove or disprove such a hypothesis. However, this is
also the case for the other main diagnostic method in urogynecology, i.e.,
multichannel urodynamics. In the meantime, it is evident that any diag-
nostic method is only as good as the operator behind the machine, and we
all know that diagnostic ultrasound is particularly operator dependent. We
all carry a responsibility to ensure that diagnostic methods are used appro-
priately, and for a fi eld as recent as pelvic fl oor ultrasound, this implies that
teaching is of paramount importance.
The volume you hold in your hands is designed with these thoughts in
mind. We would like it to be a resource for all those using or intending to
use ultrasound in the investigation of women with pelvic fl oor and lower
urinary tract dysfunction, i.e., with urinary incontinence, voiding dysfunc-
tion, recurrent urinary tract infections, and prolapse, and it may also be of
interest to those dealing with anorectal dysfunction. Its original purpose
was to provide a companion volume for courses in pelvic fl oor imaging. The
integration of 4D View software and volume data for offl ine analysis, made
possible by the support of GE Medical Ultrasound, should provide the
beginner with a simple and convenient means to train pattern recognition
and quantitative analysis.
We have taken great care to provide as much original imaging material
as was possible within the limits of the format, but it is recognized that this
fi eld is in rapid development. There is no doubt that we will be able to do
much better in the future, and the authors would like to invite all readers
to accompany us on this journey.
Hans Peter Dietz
Sydney
References
1. White RD, McQuown D, McCarthy TA, Ostergard DR. Real-time ultrasonogra-
phy in the evaluation of urinary stress incontinence. Am J Obstet Gynecol
1980;138(2):235–237.
Preface xi
2. Bernaschek G, Spernol R, Wolf G, Kratochwil A. Comparative determination of
the vesico-urethral angle in incontinence via ultrasound and lateral urethro-
cystogram (author’s transl). Geburtshilfe Frauenheilkd 1981;41(5):339–342.
3. Grischke EM, Dietz HP, Jeanty P, Schmidt W. A new study method: the perineal
scan in obstetrics and gynecology. Ultraschall Med 1986;7(4):154–161.
4. Kohorn EI, Scioscia AL, Jeanty P, Hobbins JC. Ultrasound cystourethrography
by perineal scanning for the assessment of female stress urinary incontinence.
Obstet Gynecol 1986;68(2):269–272.
5. Bergman A, McKenzie CJ, Richmond J, Ballard CA, Platt LD. Transrectal ultra-
sound versus cystography in the evaluation of anatomical stress urinary incon-
tinence. Br J Urol 1988;62(3):228–234.
6. Quinn MJ, Beynon J, Mortensen NJ, Smith PJ. Transvaginal endosonography: a
new method to study the anatomy of the lower urinary tract in urinary stress
incontinence. Br J Urol 1988;62(5):414–418.
Contents
Foreword by Stuart Campbell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
1 Live Anatomy of the Pelvic Floor: An MRI Perspective . . . . . . . 1
Lennox P.J. Hoyte
2 Pelvic Floor Ultrasound: Basic Physics, Instrumentation,
and Examination Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Hans Peter Dietz
3 3D/4D Imaging: Technical Overview and Basic Methodology . . 30
Hans Peter Dietz
4 The Anterior Compartment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Hans Peter Dietz
5 The Central and Posterior Compartments . . . . . . . . . . . . . . . . . . . 63
Anneke B. Steensma
6 Axial Plane Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Hans Peter Dietz
7 Imaging of Implant Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Hans Peter Dietz
8 Outlook . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Hans Peter Dietz
9 An Introduction to 4D ViewTM (Version 5.0) . . . . . . . . . . . . . . . . . 104
Hans Peter Dietz
Appendix: Cases for “Virtual Scanning” Using 4D View . . . . . . . . . 117
Hans Peter Dietz
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
On the DVD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
xiii
